HomeMy WebLinkAbout02-14-08
Estate of
THOMAS E. HOFFMAN, III
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
NO.2l-08- 0 IS~
PETITION UNDER SECTION 3102 OF THE PROBATE,
ESTATES AND FIDUCIARIES CODE FOR
SETTLEMENT OF SMALL ESTATE
TO THE HONORABLE JUDGES OF SAID COURT:
Sally G. Hoffinan, your Petitioner, files this Petition for Settlement of a Small Estate
under the provisions of Section 3102 of the Probate, Estates and Fiduciaries Code and in support
thereof avers that:
(1) Your Petitioner, Sally G. Hoffinan, is a competent adult residing at 104 Charles
Street, Mechanicsburg, P A 17055, and is the spouse of the above decedent.
(2) Thomas E. Hoffinan, III, spouse of the Petitioner died on December 10, 2007, at
the age of 70 years, but prior thereto lived and was domiciled at 404 Charles
Street, Mechanicsburg, Cumberland County, Pennsylvania. He died with a Will
and no letters Testamentary have been issued.
(3) Thomas E. Hoffinan, III had no probate estate when he died other than 180 shares
of Harsco Corporation stock. A copy of the stock certificates and date of death
value is attached hereto as Exhibit "A."
(4) The approximately value of the Harsco Corporation stock is $9,939.60.
(5) The sole heirs and next of kin and their relationship to the decedent are as follows:
Sally G. Hoffinan, spouse
(6) Your Petitioner avers that there are no creditors of the decedent and no claims
unpaid known to your Petitioner.
WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing
Harsco Corporation transfer all stock to Sally G. Hoffinan pursuant to Section 3102 of the
Probate, Estates and Fiduciaries Code.
By
.,--,.~,
in, ES'!l!@ ~
IR WINlM IGH11 ~ HU G:hffi:s
60 West P~mfret Street 2~ c:J
.--.., l,
Carlisle, PA 17013 .,. ~
(717) 249-2353.:,
Supreme Court #0628Z~;
~J -,:-:-~
-0
~.
---
N
U1
N
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
Sally G. Hoffman, being duly sworn according to law, deposes and says that the facts
contained in the foregoing Petition are true and correct to the best of her knowledge, information
and belief.
~['A OO-:Jih. -W-~
Sally G offman
(SEAL)
Sworn and subscri
this L day of
-
'/ . U
q;ulz J7 ..
Notary Pu6lic "
,2008.
COMMONWeAl.. 'tH..tlf ..tNNtjVLVANIA
Notarial Seal
Karen S. Noel, Notary Public
Carlisle Bora, Cumbenand County
My Commission Expires Der;. 8, 2011
Member, Pennsylvania Associalion of Notaries
JOINDER
I, Sally G. Hoffman, spouse of Thomas E. Hoffman, III, have read the Petition of my
spouse, Thomas E. Hoffman, III, for settlement of a small estate, and consent thereto and join in
the request thereof.
~~~.~
Sally offman
(SEAL)
HSC: Summary for HARSCO CP - Yahoo! Finance
YahoWeldil!l1~il;lJohctj'_IU!MStgn Out Help
b.HootFINANCE
Dow ... 0.37% Nasdaq'" 0.47%
Page 1 of2
Thu, Jan 31, 2008, 1l:20AM ET - U.S. Markets close in 4hrs 40mins.
Finance Search
Harsco Corp. (HSC)
ACnVE tflA.DlRS.
At 11:00AM ET: 55.19 'to.14 (0.25%)
. ED AIIEIlI1'RADE
i No mal
"FIde",.,
streaming quotes: ON 0
HARSCO CP (NYSE:HSC) IEditl
Last Trade: 55.19 Day's Range: 52.54 - 55.87 New! I1Y-Q!JI new Charts in Beta
52wk Range: 41.16-66.51 HSC 31-Jan 10:59a~ (C)Vahoo!
Trade Time: 11 :OOAM ET ~pm'm~':_,~':j
Change: 't 0.14 (0.25%) Volume: 542,404
Prev Close: 55.05 Avg Vol (3m): 690,387
Open: 55.87 Market Cap: 4.65B
10a~ 12p~ 2p~ 4p~
Bid: NIA PIE (ttm): 17.94 1.d .5.d .3.m 2m 1'i 2'L 5y Illi!X
Ask: NIA EPS (ttm): 3.08
1y Target Est: 71.80 Div & Yield: 0.78 (1.40%) ae~~~forHSC.
Free Trial
Ad(L~tQ-YQJ.!L..~Slt.e &i 8ili!'.!:!.S.C....tQ.P_Qr:tfQ)jQ 'Ct' Set Alert i!:. Download...Pata
Quotes delayed, except where indicated otherwise. For consolidated real-time quotes (including real-time pre/post market
data), sign up for a free trial of Real-time Quotes.
HEADLINES
Change Display [ hide...$..$. e.dlt]
[audio] Harsco Corporation Earnings
QQn~~i;!1! (live today at 2:00 pm ET)
-Outlook Roundup: Allis-Chalmers. Harsco
AP (Thu 10:32am)
-HARSCO CORp.Eiles_SEC form 8-K~ Resyl~
of Ooerations and Financial Condition
EDGAR Online (Thu 10: lOam)
-Harsco Boosts 2QQ.8.J2!.tid.<:tnce
AP (Thu 9:03am)
-Harsco Profit Soars Amid Overseas Growth
AP (Thu 8:59am)
-UPDATE - Harsco profilctLI1JJ~~record s..al.es.
at Reuters (Thu 8: 19am)
-Harsco costs rise in fourth-Quarter income
at MarketWatch (Thu 7:54am)
-Harsco profit climbs on record sales
at Reuters (Thu 7:44am)
-lnPlay: Harsco beats by $0.04. beats on revs:
guldes Q1 EPS.ll..e[QY'LCQils.ensus: guides FY08
EPS in-line
Briefing.com (Thu 7:26am)
-Harsco Reports Record Fourth Quarter and
Elill-Year_200? Resu!!~ FrQill CQotinuing
Operations
PrimeNewswire (Thu 7:25am)
-~4 2007 Harsco CQa:>Q[<:ltiQ.Q.Earnio9.S...Re~
(BM01- Before MarketQ..Qen
CCBN (Thu 7:07am)
More Headlines for HSC...
Adcl HSC News to My Yahoo':
'aMY~.lrm
FINANCIAL BLOGS
http://finance. yahoo. com! q?s= HSC
ADVERTISEMENT
Featured Video
News You Need: Google.
ElectronIc Arts
TheStreet.com TV
. Bernanke Makes His MoveCNBC.com
. Stimulus & Small Business Pt.1 FOX
Business Now
. Stimulus & Small Business Pt. 2FOX
Business Now
\~ ~ 55/ to /
qq39&lJ
1/31/2008
llJ ()
-< 0
c
z
0-<
:dJ
m[J)
;;:-
_Gl
OZ
)>1'1
,0
;;:l>
mZ
,0
-,:D
ffi~ 2j
~Ul Ui
d;rTi
:D :D
",OJ 1'1
-mo
Z::I:H
1'10
~,
-<0
t,ft om
:DOJ
l> 3Ul
c
-< m
I OJ
0 <
:D -< n
N l>:D m
1'1 zl> .Ul
0 OZ
[J) :D~ ,
Gi 1'11'1 i-
Z Gl:D i"'
l> Uil>
-< -<G)
c :Dm
:D l>z
1'1 :D-<
~':
Ifj;
Wi
\\\\:
~~\
':::
:;":
~~.
~
~
Iti~
j I,.
,/fit
I'W
:~: I
;
''\
~
~
~
~
~
'"
:;;~
~
o
N
"
~"'
.r:-.
"
..0
~.....
(/)
--I
=
l"'T'
o
=E
=
l"'T'
;::0
o
..."
..,
c
,
(\~
)>
o
)>
z
o
z
o
z
),.
III
III
m
Ul
III
l>
m
r-
m
III
:J::
)>
'"
m
Ul
o
..,
-<
:J::
m
-0
)>
'"
<
)>
r-
C
m
o
..,
~ *
m *
o *
~:z
r-
)>~
"'z
~ 1'T1
o~
f~
z * '7
~ *
..,
<:
m
o
m
z
-i
III
~
ill
!:!!
m
)>
o
:J::
o
..,
-i
:J::
m
o
o
3:
3::
o
Z
III
-i
o
o
'"
o
..,
5:!a~ :x
rJ"T10
5.""1'1
m.:;:o 0
UJ)>C ..0
OZO UJ
010 CO
OI....ON
N........
OJ
....
~ ..o-f
rno:r:
n.r:-.o
:c: 3:
)>M)'>
Z::t::VI
~),>
MA'1Tl
VIr-
txt"tI X
CVI()
;0 "T1
(i') VI"
-f3:
"t;l ),>
)> Z
.... ....
~ .....
o ....
\J1
\J1
I
OJ
\0
~
N
****..0
***\00
**..00*
*..00**
1000***
0****
'****'*
-t! '* '* '* '*
***'**
***'Jlo,*
.... '* '* '* '*
'* '* '* '* oil,
* * '11- *. *
'It
O"'Ul
....0....
...:xl....
2:(");:0
-........
~::o<
0........
zl>:xl
(/)Z~
//
I:--'
o
~
o
o
~
~
o
z
Ul
-I
o
o
;Ii;
"
c
-<
I
o
Jl
N
'"
"
Ul
Gl
z
"
-<
C
Jl
'"
~
.0;{
..P
III t
1'1
0
;0
1'1
.... ,-
>
;0
~
lD 0
< 0
c:
Z
-<
'"
""l~
::ti;i
r.,Z
'"
n"
::t
i:t.~
"'CI)"
51>1~
~~::
:t.~
..~~
O::t'"
~:t.!?
~'"i
~b
.~
)-< Ib
ZJl :t.
,,~ ~
~~ "
Gl'"
iii"
-<"
"Gl
)'"
"Z
-<
o
0-
.....
o
~
"'-
CD
~
~. .~
~~
~~
. ~ '"
U>
--i
=
,.....,
o
=E
=
,.....,
;:c
o
~
>
Z
o
Z
o
z
}.
VI
VI
'"
VI
VI
>
CD
....
fTI
'"
:J:
>
:u
'"
VI
o
...
.....
:J:
l"1
-0
)>
:0
;;
....
c::
l"1
o
...
o
Z
fTI
o
o
....
....
>
:u
)>
z
o
....:r...o :t
:r;OV'l
0-"0
3:"'I'l
M13:0 c
1.).1.0 W
0%0 .....
0.0 \#
OINO~
\11\11-1>
.....
~
:x..o.....
mo:r
t"'l~O
:;c: X
~t"'l..
Z.:t:<.A
....>
(,,';'0 fl'l
V'~
Q;)mx
c:;""'O
;:0 "
c-,VI"TI
'"Q.....~
;1:10 Z
<tl<
*
{~
~
:::r:
-
;:0
~
-<
",~
-Il-
.l-
.....
.... ....
...., ....
Q
\11
\11
~
l"1
Z
~
...
<:
M
o
fTI
Z
.....
VI
~
iu
!!!
fTI
>
o
:J:
o
...
.....
:J:
l"1
o
o
3:
3:
o
z
Ul
.....
o
o
'"
o
..,
0
,...., 0
C ~
il< {} '* J,jo. \.oJ V1
* {1- <lHlJ 0 H 3:
.e:.. ~:.. ~) 0 <Il- L)
-HoWO oil- >llo 0
\,.,IJ ,-. ~l- ~ ,,1- .r::
"'... I:-' Z
0 -Ilo .~ 0/" tl~
J,j. '\~ toll> {) olio lr1
<1:- ,'} -Ho {Io {l> [):I Ul
* -:,. ~~. -::- ,~ cr -i
i:.. ~I~ oil> .r::
.~~ -il- l:-' 0
~- .r,;zi;o{l> ",.
J,j. {~ ~:.. <llo 0 0
Z>;o ~ :A
(J)Z~
~ '- --i
:::: =
,. U>
~ :'\..
~ n
~ I"'T1
'TJ ~
c
L r ::!J
r
C '-U ,.....,
-~ )> U>
.~~ --i
OJ r> \.:0 = Z
-< 0 )> ~ 0
c 2 0
Z ..... 0 '"
~ "
'" Z 0
~ t- O '"
VI
=H J) z )0
j. ....
~
1'1'" ::J- III
D III
C))o ,..,
:tZ III
p.~ III
)> 1
...lJ) '" lD ...,. ':;;:\D-4
r
01'1 ~ ,.., 'H~I t..~; ..,
.L
~:t ~ III .1 t-. ~ J
flIt ~b ~ z
!" )> J ..... -~
1::~ ~ '" )~;~ n.>
~ ,.., ."...... .-Ii Ul
O:t.. III
\. ~b 0 -t-1 -~.,..
'.' "
c :;!'""l 'TJ Cl)om
~ \, ~~ ..; VI'.
I Z
0 , -~ ,.., (prnT
:.. ~ ~.'-..... ." ,:::-":!A ::1
N ...1Xl )>
'" !" '" 7J "
D I " ~b < C1VlT!
VI I z" ~ )> 4,:t:.
" D ~);; r
Z c 'n i>
~ ~ ,..,
" "'''' l> ",'7
... ,,~ 0
c iii" 'TJ
:v
'" ... " 0 .....
~ '" Z
" Z ,..,
:v ... ....;1 .....
0
0 ':)
r VI
r
)> U'!
'"
)>
Z
0
~
,..,
~ Z
..;
'. ~
'TJ
.. <:
,..,
0
,..,
~ Z
..;
~ III
!E
iu
!:!!
.J> ~ ,.., VI
)> 0
0 --'
z r'1 ..0' 0
0 C .c-
.Of 'TJ
..; [/) w 3:
:c H
,.., 3:
-P ~ 0 LJ
'"
0 .r 0
0 3: .r
t :z: 3:
)0 0 b' Z
ii z Ln
3: III [p n U>
)0 -i .....tn Ul
z rr :0..... --i
0 >!.....
" 0 .r = -f
-:0 ,.....,
Z '" z.....
0 0 c< C> 0
Ul " 'TJ b' .......... :::E
1'1 '" " .., :0
0 - tn =
n '" ~. ~ :!!;..... 0
" ~ ,.....,
1'1 ,- 0 ~ ~ ~ :::I;;: :::0 ~
... '" ~ !ii:o C>
"
]J z :'< tn ""T'l
-< ...
Dl
-<
n
o
c
z
-<
'"
:n
Vl
:H
"J~
C))>
:t:z
~b 0
);(/) "
~"J 8
~~ ~
"h'"
~... "
1Il'<;; ~
a:]: ..
~ ~b
-< ::J"'i
~ ~~
::! .~
~....~.. )> ~ ~
G)\ '_ Z ~ <:
z~. .. c tJ)~
>",-,"'-."""
~ . ,,\ 8 ~
~ ~ ~ ~
~ ;;0",
> z
:n-<
:.;
~
---i
=
U>
CJ
.,., T"T"I
c: ::0
.... ::j
....
,.;, ::!J
rT1
)> U>
,,0 --l
... ' )> =
:z ~
.... 0
..0 :z
0
.... z
..,. .;.
tIl
tIl t .
:;lO ::: OJ -f
tilL
~m :t>-::I:
:;;>1' ;;oa;)D
;;0 3:
tIl -731>-
:I: tr. - Ln
)>
:0 OJ <:
'"
tIl cmm
0 ;0 ;U
.,., a ::I:
-i Ie
:I:
'" ~o-n
." :t>c-n
)>
:0 Vl3:
< m:>
)> - z
....
c: -..I:>
'" ..... -c .-~
0
.,., --c.....
0 o VII-'
Z
'"
0
0
....
,...
)>
:0
)>
Z
0
-i
::IE
'"
Z
-i
""f-
.,.,
;:
'"
0
'"
Z
-i
tIl
ii>
fu Ul
UI ~
'" '"
)> ;0:-
0 (')
:I: C tJJ
0 0
~I VJ
-i H ... 0
:I: -0
'" 3:
0
0 -c
;[ C-' 3:
;[ 1I1
0 0
z ():I
tIl a- n Z
-i -C ....rn U>
0 :c....
0 ;;!.... ---i
;:0; I;-J z:C = (J')
0 0 .... ,....,
.,., c< C> -I
........
..,:c ::E
--..I - rn 0
:!:;.... =
:::!.., ,....,
Cc ;::l:l 0
z:C 0
rn -..., ~
~!~
~ ,~,
l~~
:~
~
:>:
;..
z
c:::
>oj
~
C'l
..,
c:::
::z:l
;,....,) ~
'," (FJ
"'''-
f4
i....(~ ..,
.~j/
'fI
'\'\1
~,
':~~
-
.:::,....
:."
i~
>-
~
~
~
~
~
~
,;
;j
~
~
:.."
:7~~
~
"
'"
'l
~
..
~
"
~
z:I:
m~
~ :.:
~O
"<
, t'1
::z:l
..,
"
c:::
(FJ
..,
C'l
o
~
>,~
~:.:
~~
~
~
w
~
~
~
::i
,.
~
~
~
"'~
'"
~r
~
~
~
:i
r"
I")
:t:
~~ ~
~~~ ~~
~r' ~~
g...
};~
::!:-1
h;
:--<:
, . ttl
~ ~
~ <:
~ ~~
N t"
~ 2
~ ~
~ ~
~ Iii
~ ~
s ~
~ ~
~ ~
"
~ ~.
~ :::
~
C-
:z
I-"
....
-..{)
..J
W
...,
c
r-
r-
".;,
)>
\:5
)>
z
o
z
~ ..
> -A
Ul ::z
g: a
Ul '.
Ul
)>
[I)
r-
'"
Ul
:I:
)>
:0
'"
Ul
o
...,
-i
:I:
'"
"ll
)>
:0
<
)>
r-
C
'"
o
...,
o
z
'"
o
o
r-
r-
)>
:0
)>
Z
o
-i
:e
'"
z
-i
;:
...,
<:
'"
n
'"
z
-i
Ul
:r:CO'-1
J>.....I
;:0000
;;0 :~
.... :;>;J 1>
VI ..... VI
0:; <
,- mm
;;;:;0
(;):1:
Ie
" CJ ."
l>C"
~,?:
rn J;;>
.... Z
-.Jl>
..... -0....
...... -f ....
'0 U'L......
'"
)>
n
:I:
o
...,
-i
:I:
'"
n
o
3:
3:
o
z
III
-i
o
n
:><
o
...,
n C/J
lTIen --i
::a1Tl =
:;;!ITI ,."
-::a
zITI C>
c< ::::!E
ITIITI
I:-' .... ::a =
0 - en ,."
ZITI :::0
=<....
-c C>
-.J ~::a -.,
en
--i
=
C/J
CJ
rr1
~
:::!J
rr1
C/J
--i
=
~
\JJ
-.J
.0
~
W
*
COMPANY,
R~D HANOVEll. TRUST REGISTRAR,
REG'STE FA- C'TURERS I
MANU (NEW YORK
, /)
IIt/
~
~
~
!l
lol
:l!
"(
03ZIUOH.Ln....
.3Hn..Ll>""'''OlS
/\~.
/ AV-;HORIZED OFFICER.
CJl
:I:
:>-
::0
'"
CJl
o
.,.,
:C....
:I:
z
o
z
).
CJl
CJl
'"
CJl
CJl
:>-
III
r
'"
I --l
::r:
--l 0
:::E: ~
,..,.,
Z C/)
--l
-< ,..,.,
..,.., :::J:
<:: C)
...,.,
rr ..,..,
:s:
>-
z
(Y'vJ
~~~
~.~
L'\ ....? ~ :" ~
~~S?~ ~ ~
~~~~ "
'" . <...- ~ ~, ~-
~ '" ~
~~~. 0
:\ :\ :'\" ~
~ ~ ~. 0
~.~ ~"'.
~
~ 'Ii
.~ "
( ~~'\.\ ~.'
~ !:~~
~~~
~.'
~!
~
~
..... ~.> '"
~. . ~ ~":;a ~
:::, ~'~I ::0
.....
'"
'~
~ " ~
"\" ~ " ~
\..... ~.,~
~.
"
'"
~
~,
~ :!,
~ ~.
~, ~ '. ""~
~~' ~,
~',~,:,,~:
~ ~ "~'
~ ~\',
~, '"
~\X"",:;W!"
~ · s..'I::~ 'il~"Z
~ ~ ~
~" ~
'-" ~ ~
~ ~ '\
!,,~~
~ ~'~
~~~
~~~
~..~ ~
;:;. ~. ~.'
. ~"~
" ~\
..... "
~
N
e
~
n
:I:
o
.,.,
....
:I:
'"
o
o
3:
3:
o
z
CJl
....
o
o
^
o
.,.,
~.
.~~
.~~
~
~
~
\
YH:> 3Hl 0::>
. - o~H3~SN""U...l.N""IVHNVW 35 :O.::lNOI_S"H3.LNrl
'-''''3 '>lNY8 Y-L
hit
,;t.
I~
's::
i:JJ
,A
:;:;9
~~
'h)
I.....
,r';C
,C/J
.....,..
,~
H
~
C/)
~
~
~
~
';l
~
0'
'"l
o
~
"1
~
5'
0...
<1l
::r.>
[.
o'
::l
CfJ
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fcc for (hi.;, certificate, $6.00
P 14124474
Certification Number
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
:f;'R:;:'~ ~-D::e :~,!e: 7
~1'OS.1-1j HEV 11 200ti
TYPE. PRItH IN
PERt..I.I.,NENT
Bl ACK INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on ",verse)
STATE FilE NUMBER
70
&J. Place 01 Death (Checll. only one)
Hospilal Olher
l.3lr.pdhent [] EA { Outpi:tlJenl OOOA 0 Nur~illg Home 0 ReSIdence DOther. Spe!:lty.
9. Was Deceoont 01 Hispanic Origin? 1KI No 0 Yes 10. Race: American indian, BIad. White. tt\c
(If yes. specify Cuban ($pectlYJ
Mexican. Puerto RICan, elc_l {,VfI, r &
14. Marilal Status Marrl6d, Never Married, 15. Surviving Spouse (II wile give maiden name)
Widowed, Div(l(ced (Specr/)l)
MAl2R'~D
Old Decedent
ljveina
Township?
1 Name 01 [)ecedenl (FirSt. middle, last. sLllll~)
(.) s E. HOFFmAN:rrr
5 A96 ilast Birthday) 6. Dale oj Bilth (Month, day, year)
Yr~
JUNe 30, IQ3'1
8b County 01 Death
CUr>10cl2lAN
11 DeceJent's Usual OcCll tioo (Kind 01 work done durM most 01 WQrkin life 00 not stale retired
. Kll1llolWork Kind of Busmess l IndlJ$try
Sfl/rt.s'IC.iAn/ Prl. L~B<'KfrN~~HII
. 16 Oe<:edent's M,ll~flg Address (Streel, City flown, slate, lip code)
'/0"," CHf/~,-E> Sf
/I1f(;.14';:'SI3",~G. Ptl /7t>sY
FfYlAN JR..
G /l-Or:p (Y\ A 1.1
21a Method at Disposition 0 Dooaliofl
Decedenl's
Aclual Resloonce 17a, SIale
17b County
(\,,'" 13 E,c LAN t;,
o
w
=>
..
~
19 Moltler's Name (Filst, micIde, maiden surname)
rl/EI!~>A If -rFZA /<:.
2Ob. Informant's Mailing Address (Street, cily I town, stale, lip code)
() <::Jlt:/At..65 5,
21c, Place 01 Disposilioo (Name of cemelery, cremalofy Of other place)
f(oLLI".Je, G:"'€e,.,J ;r1~IIf"l:I;"""" rA~I"
22c Name and Addresi> ot Fac~lly
tILl- NN.oI/A.... /.kJrnt. TN, 3-1", fl1A,2../LCT
23b. license Number
Appro~lmale lolerviil ParllJ: Enler other ~ru1i~sm~~,~~, 28 Did Tobacco Use Contnbule 10 Death?
On:.et 10 Dealh but nol resultmg in the underlylflQ cause gi~60 in Part lOVes 0 Probably
o No 0 Unkoown
2g, 1/ Female
o NOlprt!9fI..litwlthll)pa~ltear
o Pregnanl allime 01 death
o NoI preqnant. bull1feynilnt itltllUl 42 dioys
oIdealh
o NolprelJlklllt.bulprlJgl\dI1l43ddY51o I year
betole death
o Unknown it pregilalll Within lhe past year
32c. Place or Intury: Home, Farm, Street, Factory,
Office BulIdiog. elc. (Spea!y)
. ~
"
24 Time 01 Death f}
5' ~t) M
Items 24 26 must be cofl,pleted by per:;oo
wt.o pronounces dealh
iD
<0007
<"
CAUSE OF DEATH (See Inslructlons and lilXamples)
ll"rn 27 Pan I: E.rllerllle \J!,;w}ll!mlili: - di~a::ies, 1'l/IllIeS, O[l.:omplK:aIIOfls ~ that difectly caused lhe deillh, DO NOT enterWrmlnal e',Ient~ such as Cilrdiac ilmlst.
respiratory drre~t, Of ~enlrK;ular ilbrillallon wlU.oul showing Ihe etiology list only one cause Ol) Si:lCh Ime
D~;;ri~ir~::!r~ ,-1
Due to lor as a consequence or)
,\
,\
-1
=~A;:s5tt~S~ ~~:~~ dIS~:;'
5equoi:nllallyllslcondltlof,s, It any.
~~l~~to JNoERrv~~Au;E a
lo.Sf-ase or injury thaI t1l1tlated ltIe
events rcsulllflg Ul OOd.thj lAST.
Due 10 (or as a con~l;queflca 01)
~
~.
~
-~
'I-
30a Was an Autopsy
PE-rtDrmed1
JOb Were Autopsy Flndmgs
A\iilll<ible PriortoComplellOfi
OICilus~otDeilth/
[J 'res (3'No
31.M.>nnerol Death
~ 0 Homicioo
o Accident 0 Pendmglllvl;lstigation
o Suicide 0 Coul;:! Not be Determined
M
32d. Timeoftrlfwy
DVes
3la Cerllller (cht'Ck only ooei
ClrtilYlng physician iPh~sluan cel1lfylll~ Cd.u~e 01 dealtl wh;:n another ptIY~I(liin hilS plOflounced d1Jalh and complElted flem 231
To the besl of my knowledge, death occurred due 10 the cause(sl and manner as stakKL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
;~o:u:~~~ a;~ :~z~r;~~h:~~:~~~~:I~~ 1~~i::l:::n:n~e;::c~~:I~~;~~~~~~~(~~~ manner ai staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~
Medical hammer I Coroner
On the basis of examination and I or investigation, in my opinion. death occurred al the time, date, and place, and due to the cause(s) and manner as lilaled_ 0
I
5
~
1.11 I [..1.1 t 1d.1
0""""", ",,",,' No OtJ '~'l7 B
3 Social Security Number
1'l:J. -,30
1531
17c.D Yes, Dece<lentllved in
17d.D No, Decedent li~edWllhin
Acluallimils 01
T.p
GQ,? 0.::.,/",)
Mf(Ut:tNICSf3Ui!(;.
c,~,Q
17,,11
1701'
26, Was Case Referred 10 Medical Elt3miner I Coroner for a Reason Other than Olemallon or Donahoo?
DVes 00 No
32g location ollnfuf'V iStrael, cily I town. ~tale)
I